title: Surgical management of hepatocellular carcinoma with tumor thrombi in the inferior vena cava or right atrium.
abstract: BACKGROUND
  The prognosis for advanced hepatocellular carcinoma (HCC) with tumor thrombi in the inferior vena cava (IVC) or right atrium (RA) is poor, and there is no established effective treatment for this condition. Thus study aimed to evaluate the efficacy of surgical resection and prognosis after surgery for such cases.
  
  
  METHODS
  Between January 1990 and December 2012, 891 patients underwent hepatectomy for HCC at our institution. Of these, 13 patients (1.5%) diagnosed with advanced HCC with tumor thrombi in the IVC or RA underwent hepatectomy and thrombectomy. Data detailing the surgical outcome were evaluated and recurrence-free and overall survival rates were calculated using the Kaplan-Meier method.
  
  
  RESULTS
  Seven patients had an IVC thrombus and six had an RA thrombus. Extra-hepatic metastasis was diagnosed in 8 of 13 patients. Surgical procedures included three extended right lobectomies, three extended left lobectomies, five right lobectomies, and two sectionectomies. Right adrenal gland metastases were excised simultaneously in two patients. All IVC thrombi were removed under hepatic vascular exclusion and all RA thrombi were removed under cardiopulmonary bypass (CPB). Four patients (30.8%) experienced controllable postoperative complications, and there was no surgical mortality. The mean postoperative hospital stay for patients with IVC and RA thrombi was 23.6 ± 12.5 days and 21.2 ± 4.6 days, respectively. Curative resection was performed in 5 of 13 cases. The 1- and 3-year overall survival rates were 50.4%, and 21.0%, respectively, and the median survival duration was 15.3 months. The 1- and 3-year overall survival rates for patients who underwent curative surgical resection were 80.0% and 30.0%, respectively, with a median survival duration of 30.8 months. All patients who underwent curative resection developed postoperative recurrences, with a median recurrence-free survival duration of 3.8 months. The 1-year survival rate for patients who underwent noncurative surgery and had residual tumors was 29.2%, with a median survival duration of 10.5 months.
  
  
  CONCLUSIONS
  Aggressive surgical resection for HCC with tumor thrombi in the IVC or RA can be performed safely and may improve the prognoses of these patients. However, early recurrence and treatment for recurrent or metastatic tumors remain unresolved issues.
authors.affiliation: Department of Gastroenterological Surgery 1, Hokkaido University Graduate School of Medicine, N-15, W-7, Kita-ku, Sapporo, Japan. t-kamiya@med.hokudai.ac.jp.
authors.forename: Kenji
authors.initials: K
authors.lastname: Wakayama
authors.forename: Toshiya
authors.initials: T
authors.lastname: Kamiyama
authors.forename: Hideki
authors.initials: H
authors.lastname: Yokoo
authors.forename: Tatsuhiko
authors.initials: T
authors.lastname: Kakisaka
authors.forename: Hirofumi
authors.initials: H
authors.lastname: Kamachi
authors.forename: Yosuke
authors.initials: Y
authors.lastname: Tsuruga
authors.forename: Kazuaki
authors.initials: K
authors.lastname: Nakanishi
authors.forename: Tsuyoshi
authors.initials: T
authors.lastname: Shimamura
authors.forename: Satoru
authors.initials: S
authors.lastname: Todo
authors.forename: Akinobu
authors.initials: A
authors.lastname: Taketomi
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006528:Carcinoma, Hepatocellular / Q000150:complications / Q000401:mortality / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006325:Heart Atria / Q000473:pathology / Q000601:surgery*; D006498:Hepatectomy; D006801:Humans; D008113:Liver Neoplasms / Q000150:complications / Q000401:mortality / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D009367:Neoplasm Staging; D011183:Postoperative Complications; D011379:Prognosis; D012189:Retrospective Studies; D015996:Survival Rate; D017131:Thrombectomy; D013927:Thrombosis / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D014682:Vena Cava, Inferior / Q000473:pathology / Q000601:surgery*